Preventive Medicine 49 (2009) 39–44

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Preventive Medicine
j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / y p m e d

The association between dietary patterns and mental health in early adolescence
Wendy H. Oddy a,⁎, Monique Robinson a,b, Gina L. Ambrosini a, Therese A. O′Sullivan a, Nicholas H. de Klerk a,
Lawrence J. Beilin c, Sven R. Silburn d, Stephen R. Zubrick d, Fiona J. Stanley a
a
Telethon Institute for Child Health Research, Centre for Child Health Research, The University of Western Australia, PO Box 855, West Perth, WA 6872, Australia
b
School of Psychology, The University of Western Australia, Perth, Australia
c
School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
d
Centre for Developmental Health, Curtin University of Technology, Perth, Australia

a r t i c l e i n f o a b s t r a c t

Available online 23 May 2009 Objective. To investigate the associations between dietary patterns and mental health in early adolescence.
Method. The Western Australian Pregnancy Cohort (Raine) Study is a prospective study of 2900 pregnancies
Keywords: recruited from 1989–1992. At 14 years of age (2003–2006; n = 1324), the Child Behaviour Checklist (CBCL)
Nutrition was used to assess behaviour (characterising mental health status), with higher scores representing poorer
Mental health
behaviour. Two dietary patterns (Western and Healthy) were identified using factor analysis and food group
Adolescence
Behaviour
intakes estimated by a 212-item food frequency questionnaire. Relationships between dietary patterns, food
Raine Study group intakes and behaviour were examined using general linear modelling following adjustment for potential
confounding factors at age 14: total energy intake, body mass index, physical activity, screen use, family
structure, income and functioning, gender and maternal education at pregnancy.
Results. Higher total (b = 2.20, 95% CI = 1.06, 3.35), internalizing (withdrawn/depressed) (b = 1.25, 95%
CI = 0.15, 2.35) and externalizing (delinquent/aggressive) (b = 2.60, 95% CI = 1.51, 3.68) CBCL scores were
significantly associated with the Western dietary pattern, with increased intakes of takeaway foods,
confectionary and red meat. Improved behavioural scores were significantly associated with higher intakes
of leafy green vegetables and fresh fruit (components of the Healthy pattern).
Conclusion. These findings implicate a Western dietary pattern in poorer behavioural outcomes for
adolescents. Better behavioural outcomes were associated with a higher intake of fresh fruit and leafy
green vegetables.
© 2009 Elsevier Inc. All rights reserved.

Introduction influence mental health as expressed in behaviour and mood in

Adolescence is a crucial period of biological change and
developmental potential. Current global epidemiological data esti-
mate that one in five children is expected to develop some form of
mental health problem by the time they reach adulthood, and that
50% of all adult mental health problems develop during adolescence
(Belfer, 2008). According to one Australian national survey, 14% of 13
to 17 year olds had mental health problem scores in the clinical
range (Sawyer et al., 2000). These and other studies have
documented the association between mental health problems and
suicidal ideation and other health-risk behaviour, including smoking,
drinking and drug use (Patton et al., 2002). The World Health
Organization (WHO) recognises mental health as a major health
issue for adolescents and predicts that mental health problems will
be one of the most serious global health problems by 2020 (World
Health Organization 2005). Therefore investigating factors that
⁎ Corresponding author. Fax: +61 8 9489 7700.
E-mail address: wendyo@ichr.uwa.edu.au (W.H. Oddy).
young people is a high priority.
The limited literature to date suggests that poor nutrition is asso-
ciated with adverse mental health, however the precise relationships
between diet and mental health remain undefined (Tanskanen et al.,
2001; Sublette et al., 2006). Alongside the emergence of child and
adolescent mental health concerns, there have been radical changes in
the diets of young people (Popkin and Gordon-Larsen, 2004) as well as
global increases in the number of children and adolescents who are
overweight or obese (Wang and Lobstein, 2006). National surveys in
Australia indicate that between 1985 and 1995 intakes of total energy,
total carbohydrates, total sugars, confectionary and soft drinks increased
significantly among children aged 10 to 15 years (Cook et al., 2001).
During the same period, the prevalence of overweight has doubled and
obesity tripled and there have been marked increases in time spent on
sedentary behaviours such as watching TV or using a computer (Booth
et al., 2006) among children and adolescents. Similar findings have been
observed in other Western countries (Brownson et al., 2005).
There is evidence to suggest that relationships exist between
common mood or behavioural disorders and eating patterns, for
example, a healthy diet has been associated with better mood and

0091-7435/$ – see front matter © 2009 Elsevier Inc. All rights reserved.
doi:10.1016/j.ypmed.2009.05.009
40 W.H. Oddy et al. / Preventive Medicine 49 (2009) 39–44

cognition in older adults (Samieri et al., 2008). However, very little
research in adolescents has been reported and more investigations
have been recommended (Bamber et al., 2007). Investigating dietary
patterns has important public health implications because dietary
intake is modifiable. Further, dietary pattern analysis provides an
overall view of the diet that is not observed when evaluating
individual nutrients alone. Given the personal, societal and economic
costs of mental health and mood disorders during adolescence, the
potential role of diet in moderating these conditions is an area worthy
of exploration.
This study builds on the limited existing evidence regarding
mental well-being and nutrition in young people. We aimed to
investigate cross-sectional associations between mental health as
expressed in behaviour and mood, and dietary patterns as identified in
a population-based cohort of adolescents.
Methods
Children in Perth. Informed consent to participate in the study was obtained from the
primary caregiver as well as from the adolescent.
Mental health outcomes
Indicators of adolescent mental health were measured using the Child Behaviour
Checklist for Ages 4–18 (CBCL/4–18), a 118-item empirically validated measure and
effective screening tool for child mental health problems that was completed by the
adolescent's primary caregiver (Warnick et al., 2008). The CBCL/4–18 is a commonly
used dimensional measure of child and adolescent behaviour during the previous
6 months (Achenbach, 1991). The CBCL is used to measure behaviour as a continuous
score, in addition to apportioning factors into clinical syndrome scales including
withdrawal, somatic complaints, anxious/depressed, social, attention, thought, aggres-
sion and delinquency scales (Achenbach, 1991). A T-score for overall behaviour was
produced (Mean (M) = 46.53, Standard Deviation (SD) = 11.67), in addition to
internalizing (withdrawal, somatic complaints, anxious/depressed) (M = 46.62,
SD = 10.80) and externalizing (delinquency, aggression) (M = 48.03, SD = 11.03)
behaviour sub-scales based on clinical syndromes. For the purposes of our analyses,
continuous CBCL T-scores were used, with higher scores reflecting the presence of more
behavioural problems.

Study population Food frequency questionnaire

The Raine Study is a longitudinal pregnancy cohort study. Pregnant women
(n = 2900) were recruited between 16 and 20 weeks gestation through the public
antenatal clinic at King Edward Memorial Hospital (KEMH) and nearby private clinics in
Perth, Western Australia, from May 1989 through November 1991. To be eligible for
enrolment, the women were required to have sufficient English language skills, an
expectation to deliver at KEMH, and an intention to reside in Western Australia to allow
for future follow-up of their child (Newnham et al., 1993). A total of 2868 infants (96%)
were available at birth for follow-up.
For this study we used data collected at the 14 year follow-up, at which time 1860
adolescents participated in the follow-up (357 deferred from participating, 412 had
withdrawn from the study, 207 were lost to follow-up, and 32 were deceased), as this
was the first year that comprehensive dietary data were collected. This research was
approved by the Human Ethics Committee at KEMH and Princess Margaret Hospital for
The adolescents' usual dietary intake over the previous 12 months was assessed with a
semi-quantitative food frequency questionnaire (FFQ) developed by the Commonwealth
Scientific and Industrial Research Organisation (CSIRO) in Adelaide, Australia (Baghurst
and Record,1984). The FFQ was completed by the primary caregiver in association with the
study adolescent. Respondents were asked about their usual frequency of consumption of
212 food and beverage items, excluding alcohol, and how their usual serve compared to a
standard serve size given in household measurements (spoons, cups, slices, etc). All
completed FFQ were checked by a research nurse and missing or unclear responses were
clarified when the adolescent attended their physical assessment. The CSIRO entered and
verified the FFQs and provided estimates of daily intakes of foods and nutrients using
Australian food composition data. This FFQ has been shown to correctly rank a reasonable
proportion of most nutrient intakes when compared to a 3-day food record in this cohort
(Ambrosini et al., in press).

Table 1
Food groups included in the factor analysis (Ambrosini et al., 2009).

Food group FFQ items

Wholegrains Wholemeal, mixed grain or high-fibre sliced bread, oatmeal muesli, bran, wheat germ, other wholegrain breakfast cereals
Refined grains White bread or rolls, refined breakfast cereals, crumpets, muffins, crisp bread, crackers, salted biscuits, rice, noodles, pasta
Red meats Beef, lamb, pork, pureed meat dishes, schnitzel, offal, mince dishes hamburger patty (without bun)
Processed meat Sausages, frankfurters, bacon, ham, fritz-devon, salami
Poultry Roast or boiled chicken
Meat-based mixed dishes Stew, casserole, Chinese meat and vegetables, curry, goulash
Takeaway foods Hamburger with bun, pizza, fried chicken, sausage roll, meat pie, savoury-filled pastry
Fried fish Fried fish, battered fish
Other fish Steamed, grilled or canned fish, other seafood
Fried potatoes Hot chips (french fries), potato gems (pommes noisettes)
Potato Boiled, mashed, roasted, canned or dried potato, potato salad
Yellow or red vegetables Carrots, pumpkin, capsicum
Other vegetables Beetroot, zucchini, sweet corn, mushrooms, olives, celery, turnip swede, onion, cucumber, mixed vegetables
Legumes Haricot, lima, broad or green beans, peas, baked beans, lentils
Cruciferous vegetables Cabbage, brussels sprouts, broccoli, cauliflower, coleslaw
Leafy green vegetables Silverbeet, lettuce
Tomato Fresh and cooked tomato
Fresh fruit Orange, apple, banana, fruit salad, berries, melons, peach, plum nectarine, apricot, grapes, pineapple, avocado
Canned fruit Fruit canned in syrup or juice
Dried fruit Sultanas, raisins, currants, other dried fruit
Cakes, biscuits, sweet pastries Fruit loaf, sweet bun, doughnut, croissant, biscuits, cake, fruit pie or pastry, steamed pudding
Low fat dairy products Reduced fat milk, skim milk, flavoured milk, Sustagen, low fat cheese, cottage cheese
Full fat dairy products Whole milk, cream, ice-cream, full fat yoghurt, full fat cheese, thick shakes
Soy milk Soy milk
Milk-based dishes Milk pudding, mornay dishes, custard
Confectionary Chocolate, chocolate covered bars, lollies, toffees, icy poles
Added sugar Honey, jam, marmalade, spooned sugar
Crisps Potato crisps, corn chips
Nuts Peanuts, other nuts (salted and unsalted)
Sauces Mayonnaise, salad cream, thick sauces e.g. brown sauce
Soups Canned soup, packet soup, homemade soup
Eggs Fried, boiled, scrambled egg, omelette
Tea, coffee Tea, herbal tea, coffee, coffee substitute, decaffeinated coffee
Soft drinks Coca cola, mineral water, other soft drinks, cordial fruit drink (b = 35% fruit juice)
Mineral water (plain) Spring water
Juice Pure fruit juice, vegetable juice
Solid spreads Butter, butter/margarine blend, lard, table margarine
Unsaturated spreads Canola or other monounsaturated fat margarine, polyunsaturated margarine, low fat spreads
 W.H. Oddy et al. / Preventive Medicine 49 (2009) 39–44 41

Dietary patterns based on factor analysis have been used in several settings and have Table 2
been shown to be suitable for describing usual dietary intake (Newby and Tucker, 2004). Dietary patterns and their factor loadingsa in the Raine cohort at 14 years (Perth,
We have previously identified dietary patterns using exploratory factor analysis in this Western Australia 1989–2006) (Ambrosini et al., 2009).
cohort at age 14 years (Ambrosini et al., 2009). Firstly, the 212 foods listed in the FFQ were
collapsed into 38 food groups devised a priori (Table 1) and similar to those used by others Factor loadingsa
(Hu et al., 2000). All 38 food groups were included in a factor analysis (maximum ‘Healthy’ pattern ‘Western’ pattern
likelihood method) using SAS (SAS, 2002–2003). We used parameters similar to those in
Yellow or red vegetables 0.56 0.12
other studies of dietary patterns (Hu et al., 2000): only factors with an eigenvalue N1 were
Leafy green vegetables 0.49 0.00
retained in the factor solution, the scree plot was used to confirm the number of factors to
Tomato 0.49 0.00
retain, and varimax rotation was applied to improve factor interpretation. Two
Cruciferous vegetables 0.48 0.27
independent factors or dietary patterns were identified which explained 50% and 34% of
Other vegetables 0.66 0.22
the total variance respectively, and we labelled these patterns ‘Healthy’ and ‘Western’ due
Fresh fruit 0.48 − 0.02
to the foods that contributed to each pattern (Ambrosini et al., 2009). Food loadings onto
Legumes 0.43 0.19
each dietary pattern are shown in Table 2. Those food groups having a factor loading of 0.30
Wholegrains 0.39 − 0.12
or more were regarded as important contributors to the dietary patterns. All adolescents
Fish, steamed, grilled or tinned 0.33 0.05
received a score for both dietary patterns measured on the z-score scale, which was based
Takeaway foods − 0.20 0.53
on their FFQ intakes and the factor loadings for each food in Table 2.
Confectionery − 0.14 0.46
Red meat 0.14 0.46
Control variables Refined grains 0.03 0.42
Processed meats −0.02 0.41
We adjusted for a variety of factors that could potentially confound the relationship Potato, fried e.g. french fries − 0.25 0.39
between dietary patterns and mental health. Crisps −0.22 0.39
Soft drinks − 0.18 0.37
Total energy intake Cakes, biscuits 0.10 0.34
We adjusted for total energy intake (megajoules) in the multivariable models to Potato, not fried 0.21 0.34
ensure that observed associations between dietary patterns and mental health scores Sauces and dressings 0.13 0.34
were independent of the adolescents' total energy intake. This adjustment controls for Full fat dairy products 0.00 0.30
extraneous variation and was conducted because most nutrient intakes in free living Soups 0.26 0.26
populations are positively correlated with total energy intake (Willett and Stampfer, Canned fruit 0.26 0.11
1986). Furthermore, some nutrients may be associated with disease on the basis of their Meat dishes 0.26 0.15
correlation with energy intake (Lyons et al., 1983). Dried fruit 0.23 0.00
Mineral water 0.23 − 0.05
Low fat dairy products 0.22 −0.10
Lifestyle factors
Eggs 0.20 0.24
The adolescents in the study were asked how often they exercised outside of school
Juices 0.19 − 0.02
hours per week, where exercise was defined as activity causing breathlessness or
Nuts 0.17 − 0.02
sweating. These data were grouped based on previous studies (Ambrosini et al., 2009;
Added sugar 0.13 0.21
O'Sullivan et al., 2009) as: i) exercise less than once a week, ii) exercise one to three
Milk dishes 0.13 0.20
times per week, and iii) exercise more than three times per week. Adolescents were
Fish, fried or battered 0.02 0.23
also asked about their television or video viewing and computer use, including video
Poultry 0.01 0.29
games, measured as hours per day of combined screen use. We grouped these data as: i)
% Variance 50 34
less than 2 h/day, ii) 2 to 4 h/day, and iii) more than 4 h/day.
a
Foods having a factor loading of ≥ 30 are highlighted in bold.
Physical measurements
A trained research assistant recorded height and weight measurements using
standard calibrated equipment. Body mass index (BMI: weight (kg)/height (m)2) was
All data analyses for this study were conducted with SPSS Version 15.0 (SPSS Inc.,
calculated and subjects were grouped into underweight, normal weight, overweight,
2006).
and obese categories according to Cole et al. (2007, 2000) using standard criteria for
this age group.
Results
Sociodemographic and family characteristics
The primary caregiver provided information on maternal education, current Of the 1784 primary caregivers who completed the CBCL, 1598 also
family income and family structure. Maternal education, assessed as a continuous provided complete dietary pattern data for analysis. The mean age of
variable, represented the highest completed year of secondary education. The current
annual income for the household before tax was analysed as a categorical variable
the study adolescents was 14.01 (SD ± 0.2 years), and the range was
and family structure was assessed as either ‘yes’ or ‘no’ for living in a single parent 13.0–15.0 years. Characteristics for the sample are given in Table 3.
family. Family functioning was assessed with the General Functioning Scale from the Table 4 presents univariable and multivariable linear regression
McMaster Family Assessment Device (Epstein et al., 1983) that consisted of questions results between behaviour scores and dietary patterns. In univariable
on family communication, affective responsiveness, and behaviour control. The scale
analyses, significantly lower CBCL T-scores for total behaviour and
has been shown to be reliable and internally consistent (Byles et al., 1988), with
lower scores on the General Functioning Scale representing poorer family functioning externalizing behaviour were associated with the Healthy dietary
and higher scores representing better family functioning. pattern, although this association was weakened following adjust-
ment for total energy intake, gender, BMI category, physical activity,
Statistical analysis screen use, family structure, family income, family functioning score,
and maternal education at pregnancy. In both univariable and
Three continuous CBCL T-scores were examined to study the behavioural
outcomes: 1) total CBCL score, 2) internalizing score and 3) externalizing score. The
multivariable analyses, all CBCL scores were positively associated
residuals were analysed to confirm that our model was a good fit. We then analysed the with higher Western pattern scores. In the multivariable model, the
associations between continuous dietary pattern scores and each behavioural outcome Western dietary pattern was significantly associated with a higher
using a generalized linear model. In the univariable model, the ‘Western’ and ‘Healthy’ total behaviour score (b = 2.20, 95% CI = 1.06, 3.35), internalizing
dietary pattern scores were adjusted for each other. These analyses were then repeated
score (b = 1.25, 95% CI = 0.15, 2.35) and externalizing score (b = 2.60,
with the inclusion of potential confounding variables. We tested for two-way
interaction effects between our predictor variables and control variables and found 95% CI = 1.51, 3.68).
no significant results, therefore we did not include interactions in the final model. Associations between total CBCL score and intakes of food groups
In addition, we attempted to identify key components of the dietary patterns that in quartiles are presented in Table 5. Significantly lower total CBCL
might explain significant associations between the dietary patterns and mental health scores and decreasing trends in total CBCL scores were observed with
outcomes. Intakes of food groups with a factor loading ≥0.30 on the Western or Healthy
pattern (Table 2) were converted into quartiles depending on their score and entered
increased intakes of leafy green vegetables and fresh fruit. On the
into separate generalized linear models with potential confounding variables to test for other hand, higher CBCL scores were seen for adolescents in the
associations with total, internalizing and externalizing CBCL scores. highest intake quartiles for takeaway foods (b = 1.89, 95% CI = 0.07,
42 W.H. Oddy et al. / Preventive Medicine 49 (2009) 39–44

Table 3 inner distress (Achenbach and McConaughy, 1997) and provide

Frequency data for Raine cohort at 14 years (Perth, Western Australia 1989–2006). support for existing research linking a poor quality diet to externaliz-
Sample (n = 1598) ing behaviour (Liu et al., 2004). Items that make up the externalizing
Mean SD score include bragging, lying, running away, stealing, truancy, arguing,
Daily energy intake (MJ) 9.6 3.0 fighting, disobedience, sudden mood changes, and temper tantrums,
Missing 3 and are often termed ‘conduct problems’ (Achenbach and McCo-
Maternal education at birth naughy, 1997).
Highest school year 11.0 1.0 Within the Western dietary pattern, three key food groups;
Missing 4
Family functioning scorea 29.3 5.6
takeaway foods, red meat and confectionary, were associated with a
Missing 49 higher total CBCL score. Confectionary products are generally high in
refined sugar, energy dense and low in essential micronutrients, and
n % are often eaten in the place of more nutrient-dense foods (National
Body mass index (BMI) Underweight 88 5.5 Health and Medical Research Council, 2003). It has been estimated
Healthy weight 960 60.1
that a quarter of adolescents' daily energy intake is in the form of
Overweight 256 16.0
Obese 102 6.4
snacks (Summerbell et al., 1995), which suggests that confectionary
Missing 192 12.0 may be replacing more nutritious foods. Red meat is an important
Family income (AUD) ≤$25,000 pa 191 12.0 provider of the essential nutrients for brain functioning including iron,
$25,001 pa–$50,000 pa 425 26.6 zinc, vitamin B12 and niacin (Bodnar and Wisner, 2005). However, red
$50,001 pa–$78,000 pa 433 24.2
meats, along with takeaway foods, tend to be sources of saturated fat,
N$78,000 pa 520 32.5
Missing 29 1.8 which can contribute to insulin sensitivity and metabolic syndrome
Single parent family Yes 313 19.6 (Riserus, 2008). The associations of fruits and leafy green vegetables
No 1282 80.2 with lower behaviour scores in our study may be due to their
Missing 3 0.2
micronutrient content, in particular folate required for neurotrans-
Gender Male 818 51.2
Female 779 48.7
mitters (Bodnar and Wisner, 2005) and antioxidants (e.g. vitamin C,
Missing 1 0.1 carotenoids and vitamin E) for preventing inflammation, which has
Physical activity b1/week 125 7.8 been associated with depressive states (Ford and Erlinger, 2004) and
1–3 times/week 620 51.3 is closely linked with metabolic syndrome (Giugliano et al., 2006). The
4+ times/week 459 28.7
result observed for fresh tomato and internalizing and externalizing
Missing 194 12.1
Screen use b2 h/day 377 23.6 behaviour observed could be explained by the high lycopene content
2–4 h/day 558 34.9 of tomato. Lycopene gives tomatoes a strong antioxidant activity and
4+ h/day 452 28.3 assists in decreasing oxidative stress and free radical cell damage
Missing 211 13.2 (Frusciante et al., 2007). Major depressive disorder has been
a
Assessed with General Functioning Scale from the McMaster Family Assessment associated with oxidative stress (Sarandol et al., 2007), and a positive
Device. relationship has been reported between the potency of oxidative
stress and severity of depression (Yanik et al., 2004). Finally, there is a
3.71), red meat (b = 1.98, 95% CI = 0.20, 3.76) and confectionary growing body of research examining essential fatty acids and mental
(b = 2.63, 95% CI = 0.87, 4.39). health that suggests a diet high in essential fatty acids is associated
Although the results are not shown, we found that a high intake of with better mood and cognition (Hallahan and Garland, 2005).
fresh tomato was associated with lower internalizing behaviour scores
(b = −1.64, 95% CI = −3.10, − 0.18) and lower externalizing scores Study limitations and strengths
(b = −2.13, 95% CI = −3.75, −0.51). Further, lower externalizing
scores were linked to the highest quartile of intake for leafy green To our knowledge this is the first population-based study to
vegetables (b = − 2.05, 95% CI = − 3.76, − 0.34). The highest quartile examine mental health as assessed by behavioural scores and dietary
for confectionary intake was associated with higher scores for
internalizing (b = 1.91, 95% CI = 0.22, 3.59) and externalizing beha- Table 4
viour (b = 2.53, 95% CI = 0.86, 4.20). Takeaway foods (b = 2.47, 95% Univariable and multivariable linear regression coefficients for Child Behaviour
CI = 0.74, 4.20), red meat (b = 1.88, 95% CI = 0.19, 3.58) and potato Checklist T-scores at 14 years for Healthy and Western dietary patterns in the Raine
cohort (Perth, Western Australia 1989–2006) [n = 1324].
crisps (b = 1.85, 95% CI = 0.16, 3.54) were also associated with higher
externalizing scores. CBCL total CBCL CBCL
internalizing externalizing

Discussion Score for Healthy dietary pattern

Unadjusted beta coefficienta − 1.06 − 0.57 − 0.97
(95% CI) (− 1.68, − 0.44) (−1.16, 0.02) (− 1.55, − 0.38)
Our results show that higher CBCL scores, representing poorer p-value 0.001 0.057 0.001
mental health in early adolescence, were associated with an increased Adjusted beta coefficientc − 0.24 0.17 − 0.29
intake of the Western dietary pattern, particularly takeaway foods, red (95% CI) (− 0.97, 0.50) (− 0.54, 0.88) (− 0.98, 0.42)
meat and confectionary (components of this pattern). We found that p-value 0.528 0.642 0.419
Score for Western dietary pattern
improved behavioural scores were associated with higher intakes of
Unadjusted beta coefficientb 2.69 1.27 2.95
leafy green vegetables and fruit but not with an overall Healthy dietary (95% CI) (2.05, 3.33) (0.67, 1.87) (2.35, 3.55)
pattern. p-value b 0.001 b0.001 b 0.001
The size of the regression coefficients linking the Western dietary Adjusted beta coefficientc 2.20 1.25 2.60
(95% CI) (1.06, 3.35) (0.15, 2.35) (1.51, 3.68)
pattern and CBCL T-scores (Table 4) was larger in the adjusted model
p-value b 0.001 0.026 b 0.001
for externalizing behaviour (delinquent and/or aggressive behaviour)
a
in comparison with internalizing behaviour (withdrawal, somatic Adjusted for Western pattern score.
b
Adjusted for Healthy pattern score.
complaints, anxious/depressed behaviour). These findings suggest c
Analysis adjusted for: total energy intake, BMI category, physical activity, screen
that the associations observed in this study may manifest more in the use, family structure, family income, family functioning and gender at age 14 and
behaviour of the child in relation to others, rather than as symptoms of maternal education at pregnancy.
 W.H. Oddy et al. / Preventive Medicine 49 (2009) 39–44 43

Table 5
Multivariable general linear model analyses: Child Behaviour Checklist T-scores for total behaviour at 14 years and individual food groups in the Raine cohort (Perth, Western
Australia 1989–2006).

Quartiles of intake (n = 1324) p for trenda

1 2 3 4
Healthy pattern
Yellow/red vegetables b 1.00 − 0.09 − 0.65 −0.51 0.46
(95% CI) (− 1.79, 1.61) (− 2.35, 1.05) (−2.24, 1.23)
Leafy green vegetables b 1.00 − 0.35 − 2.28⁎ −1.98⁎ 0.01⁎
(95% CI) (− 2.14, 1.44) (−4.08, − 0.48) (− 3.80, −0.16)
Tomato b 1.00 0.98 − 1.18 − 0.90 0.09
(95% CI) (−0.73, 2.68) (− 2.71, 0.34) (− 2.53, 0.73)
Cruciferous vegetables b 1.00 0.00 0.48 0.77 0.31
(95% CI) (−1.65, 1.65) (− 1.16, 2.12) (− 0.92, 2.46)
Other vegetables b 1.00 − 0.48 − 0.34 − 0.19 0.87
(95% CI) (−2.12, 1.17) (− 2.00, 1.33) (− 1.90, 1.52)
Fresh fruit b 1.00 − 0.37 − 0.61 − 2.16⁎ 0.02⁎
(95% CI) (−2.00, 1.27) (− 2.31, 1.09) (− 3.92, −0.41)
Legumes b 1.00 0.23 0.59 1.27 0.13
(95% CI) (− 1.42, 1.87) (−1.07, 2.24) (− 0.40, 2.95)
Wholegrains b 1.00 − 0.03 − 0.26 − 1.06 0.22
(95% CI) (− 1.69, 1.64) (−1.91, 1.40) (− 2.77, 0.65)
Fish, steamed, grilled or tinned b 1.00 − 0.80 − 0.27 − 1.32 0.18
(95% CI) (− 2.51, 0.91) (− 1.84, 1.30) (−2.94, 0.29)

Western pattern
Takeaway foods b 1.00 0.28 0.21 1.89⁎ 0.07
(95% CI) (−1.38, 1.95) (− 1.49, 1.90) (0.07, 3.71)
Confectionary b 1.00 1.71⁎ 1.52 2.63⁎⁎ 0.01⁎
(95% CI) (0.07, 3.34) (− 0.12, 3.16) (0.87, 4.39)
Red meat b 1.00 1.33 1.08 1.98⁎ 0.05⁎
(95% CI) (− 0.31, 2.96) (−0.62, 2.77) (0.20, 3.76)
Refined grains b 1.00 0.70 0.24 − 0.14 0.77
(95% CI) (−0.97, 2.37) (−1.44, 1.91) (− 1.98, 1.70)
Processed meat b 1.00 − 0.73 −0.86 0.05 0.99
(95% CI) (−2.39, 0.92) (− 2.57, 0.84) (− 1.72, 1.82)
Potato, fried b 1.00 0.47 1.14 1.39 0.12
(95% CI) (− 1.48, 2.43) (− 1.48, 3.77) (−0.43, 3.22)
Crisps b 1.00 1.07 1.08 0.76 0.33
(95% CI) (− 1.62, 3.75) (− 0.88, 3.05) (− 1.04, 2.56)
Soft drinks b 1.00 1.93⁎ 1.45 0.52 0.63
(95% CI) (0.29, 3.57) (− 0.20, 3.10) (− 1.23, 2.28)
Cakes, biscuits b 1.00 − 1.16 − 1.48 − 1.11 0.74
(95% CI) (− 2.83, 0.51) (− 3.21, 0.25) (− 2.97, 0.76)
Potato not fried b 1.00 0.54 1.08 0.51 0.44
(95% CI) (−1.10, 2.18) (−0.59, 2.75) (− 1.22, 2.24)
Sauces and dressings b 1.00 0.56 0.29 1.07 0.29
(95% CI) (−1.19, 2.32) (− 1.46, 2.05) (− 0.67, 2.80)
Full fat dairy products b 1.00 −0.04 − 0.15 − 0.25 0.76
(95% CI) (−1.71, 1.63) (− 1.85, 1.56) (−2.09, 1.61)
⁎p b 0.05, ⁎⁎p b 0.005, reference category is the first quartile of intake. Each analysis for each specific food adjusted for: total energy intake, BMI category, physical activity, screen use,
family structure, family income, family functioning and gender at age 14 and maternal education at pregnancy.
a
Obtained by analysing quartiles of food intake as continuous variable.

patterns in an adolescent population, although a recent study has
examined younger children (Wiles et al., 2007). Our study has a
number of strengths. Importantly, we were able to control for a variety
of potential confounders, including psychosocial and demographic
factors, physical activity and sedentary behaviour (television viewing
and computer use). We used a valid and reliable measure of
adolescent behaviour (Warnick et al., 2008) and the large sample
size allowed for good response fractions. By analysing dietary patterns
the effect of the whole diet was considered (Hu, 2002). While there
are other empirical methods available for identifying major dietary
patterns, for example cluster analysis, we used factor analysis because
this method is more commonly used in the nutritional epidemiology
literature (Newby and Tucker, 2004) and has been shown to be a
reliable method for identifying dietary patterns (Khani et al., 2004).
The FFQ was completed by the primary caregiver in association with
the adolescent to reduce calculation error because it may be difficult
for young adolescents to estimate out how often food is consumed and
in what portion size (Margetts and Nelson, 1997). However, the cross-
sectional design of this study does not allow causal relationships to be
established. Although the relationships persisted after adjustment for
familial factors and socio-economic status these potentially did not
fully account for social factors influencing eating patterns. Dietary
patterns may be influenced by mood or emotional distress, which can
induce a preference for sweet carbohydrate (confectionary) or fat-
rich snack foods in order to enhance mood (Christenson, 1997).
Finally it is possible that, due to the many statistical tests conducted,
some of the significant findings for the food groups may be due to
chance.
Conclusion
In summary, we have shown in a population cohort of adolescents
that behavioural scores were correlated with dietary patterns. Our
study suggests that poorer behaviour in early adolescence, after
adjustment for socio-economic and lifestyle factors, was associated
with a Western dietary pattern (a diet high in red and processed
meats, takeaway foods, confectionary and refined foods). The results
of our study have important implications for public health policy-
44 W.H. Oddy et al. / Preventive Medicine 49 (2009) 39–44
makers, given that diet is a modifiable risk factor. To date this is one of
the few studies to report on the associations between mental health
and dietary patterns in an adolescent population and therefore further
studies are required to support our findings.
Conflict of interest statement
The authors declare that there are no financial interests or conflicts of interest to
disclose.
Acknowledgments
The Western Australian Pregnancy Cohort (Raine) Study is funded
by the Raine Medical Research Foundation at The University of
Western Australia, the National Health and Medical Research Council
of Australia (NHMRC), the Telstra Foundation, the Western Australian
Health Promotion Foundation, and the Australian Rotary Health
Research Fund. We would also like to acknowledge the Telethon
Institute for Child Health Research, the Commonwealth Scientific and
Industrial Research Organisation (CSIRO), and the NHMRC Program
Grant which supported the 14-year follow-up (Stanley et al., ID
003209). We are extremely grateful to all the families who took part in
this study and the whole Raine Study team, which includes data
collectors, cohort managers, data managers, clerical staff, research
scientists and volunteers.
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